RU2150243C1 - Method for making duodenojejunostomy in cases of ring-shaped pancreas - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves transversely dissecting the duodenum above the ring-shaped pancreas. Distal part of the duodenum is sutured. The initial portion of the jejunum is crossed in transverse direction. The proximal portion of the duodenum is connected to the distal portion of the jejunum by making anastomosis. EFFECT: improved motor and evacuation function of proximal portion of the duodenum. 1 dwg

Description

 The invention relates to medicine, namely to surgery, and can be used for applying duodenojejunostomy with annular pancreas.

 A known method of applying a bypass duodenojejunostomy with the annular pancreas, which uses the initial loop of the jejunum, which is carried out to the duodenum through the hole in the mesentery of the transverse colon and isoperistically placed next to the proximal duodenal segment. The latter is longitudinally dissected and an anastomosis is applied with a loop of the jejunum “side to side” with a two-row suture (“Surgery of the pancreas in children. G. A. L. Bairov, 1978, p. 39-41).

 The disadvantages of this method of duodenoejunoanastomosis are a violation of the motor-evacuation function of the proximal duodenum during its longitudinal dissection, the development of the “lead loop” syndrome in the long-term, in which bile and pancreatic juice accumulate in the short initial segment of the jejunum, the progression of reflux gastritis casting stagnant contents from the lumen of the adducting loop into the duodenum and stomach.

 The invention is aimed at solving problems: improving the motor-evacuation function of the proximal duodenum, prevention of the syndrome of the “lead loop” and reflux gastritis.

 Tasks are achieved by switching off the distal duodenum from the passage and applying an anastomosis between the proximal part of the duodenum and the isolated loop of the jejunum.

 The novelty of the method is that after crossing the duodenum over the annular pancreas, the distal end of the duodenum is sutured, the initial segment of the jejunum is transversely intersected, the proximal end of the duodenum is anastomosed with the distal segment of the jejunum and the anastomosis is applied.

 The method is depicted in the drawing, which shows a General diagram of the operation.

1 - the distal end of the duodenum;
2 - the initial segment of the jejunum;
3 - distal segment of the jejunum;
4 - proximal end of the duodenum.

 The method is as follows: after mobilization of the duodenum according to Kocher and clarification of the anatomical relationships, the descending branch of the duodenum is separated from the pancreatic head for 1.5-2 cm by ligation and intersection of short pancreatoduodenal vessels. The duodenum is crossed in the transverse direction above the annular pancreas, the distal end of the duodenum (1) is sutured with a two-row suture. After the duodenojejunal transition is reduced, 15–20 cm from the Treitz ligament are transversely intersected with the initial segment of the jejunum (2), the distal segment of the jejunum (3) and passed through the hole in the mesentery of the transverse colon. Between the proximal end of the duodenum (4) and the distal segment of the jejunum (3), an end-to-end anastomosis is applied with a single-row continuous suture. Patency of the gastrointestinal tract is restored by applying the end-to-side inter-intestinal anastomosis between the initial and distal sections of the jejunum 30–40 cm distal to the duodeno-anastomosis.

 Examples of specific performance.

 1. Patient O., born in 1990, was admitted to the planned surgery department of Children's Clinical Hospital No. 15 of Perm on 08/19/98 with complaints of periodic vomiting, which often occur in the morning or after eating a large amount of food, and lack of body weight. Complaints of regurgitation and vomiting appeared at 6 months of age.

 With fibrogastroduodenoscopy - the esophagus is freely passable, the cardia is functioning. In the stomach, a moderate amount of contents, the antrum mucosa is moderately tuberous, opaque, a pylorus of a rounded shape, closes. The lumen of the bulb and the upper horizontal branch of the duodenum is somewhat enlarged, there is compression of the intestine from the outside with a clear boundary between the enlarged and narrowed sections. Large and small duodenal papillae are located below the narrowing. Conclusion: Chronic granular gastritis. Duodenostasis.

 Relaxation duodenography - in the middle third of the vertical part of the duodenum there is an asymmetric narrowing of the lumen to 0.5 cm in length up to 2.5 cm, in conditions of relaxation of the expansion of the lumen of the duodenum does not occur. Conclusion: radiological signs of the annular pancreas.

 Computed tomography - the pancreas is enlarged in the head region to 3.4x3.0x3.0 cm, squeezed in front and partially behind the descending part of the duodenum, causing narrowing of the lumen. Conclusion: the ring-shaped pancreas.

 Operation 09/03/98 - Median laparotomy. An audit found that the head of the pancreas in the form of a ring covers the descending part of the duodenum in its middle third. Above the narrowing, the intestine is moderately expanded, the stomach is slightly enlarged. The gall bladder is enlarged, tense, does not empty, has a fixed constriction in the body area. The funnel-cervical region is helically curved, deformed by adhesions, which almost completely block the exit from the gallbladder. The cystic duct is elongated to 3 cm, narrowed and flows into the common bile duct in the retroduodenal region.

 Puncture cholecystocholangiography - contrast from the gallbladder to the cystic and common bile ducts is not received. Performed cholecystectomy. The duodenum is mobilized according to Kocher. Immediately proximal to the annular pancreas, the duodenum is separated from the pancreatic head and crossed in the transverse direction. The diameter of the intestinal lumen at the level of the pancreatic ring is less than 0.5 cm. The distal end of the crossed duodenum is sutured with double-row sutures. 15 cm from Treitz the jejunum is transversely crossed, its distal end is mobilized, carried out posteriorly to the duodenum. An anastomosis of the proximal duodenum and distal jejunum end-to-end section was imposed. The posterior lip of the anastomosis is made with a double-row suture, the front lip with a single-row continuous suture. 35 cm distal to the duodenoeunoanastomosis, end-to-side enteroenteroanastomosis was applied between the initial and distal sections of the jejunum. Installed irrigator for enteral nutrition. The postoperative course is smooth. Discharged in satisfactory condition on September 15, 1998.

 Viewed after 6 months. The condition is satisfactory. There are no complaints. I added 3 kg in weight. Control fluoroscopy dated 04/16/99 - The esophagus is freely passable, the stomach is somewhat hypotonic, evacuation from it is not impaired - portioned, obstruction in the area of duodenojejunostomy is not detected. After 2 hours, all the contrast in the small intestine.

 2. Patient P., born in 1984, was admitted to the planned surgery department of Children's Clinical Hospital No. 15 in Perm on 11/23/98 with complaints of periodic pain in the epigastric region and left hypochondrium after eating and physical exertion, nausea, belching with air, and vomiting mixed with bile. The patient considers himself from the age of 7, was repeatedly examined and treated by a gastroenterologist, there was no effect from the treatment.

 With fibrogastroduodenoscopy, the esophagus is without features, the cardiac pulp functions, a moderate amount of bile in the lumen of the stomach, the pylorus is gaping. The mucous membrane of the bulb is loose, compression is determined from the outside of the descending part of the duodenum. The large duodenal papilla is adenomatically altered. Conclusion: Partial duodenal obstruction. Polyp of the large duodenal papilla.

 Relaxation duodenography - in the middle third of the descending branch of the duodenum there is a persistent uneven narrowing of the lumen from the outside, which persists under conditions of relaxation. Conclusion: the ring-shaped pancreas.

 Retrograde cholangiopancreatography - the common bile duct is slightly expanded, flows into the lower horizontal branch of the duodenum, in the area of the large duodenal papilla, a filling defect is determined. The gallbladder has an inflection in the region of the body, the cystic duct is elongated, flows into the common bile duct in the retroduodenal part. The Wirsung duct pass, in the region of the head of the gland, an additional branch departs from it, which in the form of a half-ring covers the duodenum. Conclusion: The ring-shaped pancreas. Anomaly of the cystic duct and gall bladder.

 Computed tomography - there is a compression of the head of the pancreas of the descending part of the duodenum increased to 3.2 cm at the level of discharge of a large vessel. Conclusion: the ring-shaped pancreas.

 Operation 03.12.98. Upper median laparotomy. The stomach is slightly enlarged, the pylorus is enlarged. Mobilization of the duodenum according to Kocher. There is an increase in the head of the pancreas, which in the form of an incomplete ring compresses the duodenum in the middle third of the descending branch. At the level of the incomplete annular gland, an abnormally located large pancreatoduodenal artery passes along the antero-lateral surface of the duodenum. The gall bladder is reduced in size, has an excess of the body. The cystic duct is fibrosed, elongated, runs along the common bile duct and flows into the latter in the retroduodenal part. Cholecystectomy The duodenum is crossed in the transverse direction immediately above the level of compression by the abnormal artery and the semiring of the pancreas. Adenoma of the large duodenal papilla was excised, papillosphincteroplasty was performed. Through the stump of the cystic duct, a choledochostoma is superimposed. The dietary section of the duodenum is sutured with a two-row suture. After reduction of the duodenojejunal transition 20 cm from the Treytz ligament, the jejunum is transversely crossed, its distal portion is mobilized and performed posteriorly. An end-to-end anastomosis is applied between the proximal duodenum and the distal jejunum with a single-row continuous suture. The proximal part of the duodenum is fixed in the "window" of the mesocolon. 35 cm distal to the duodenojejunoanastomosis, end-to-side enteroenteroanastomosis was applied between the initial and distal sections of the jejunum. Installed irrigator for enteral feeding. The postoperative period was uneventful. Discharged in satisfactory condition on 12/20/98.

 Viewed after 6 months. after operation. Satisfactory condition, no complaints.

 The positive effect of using the proposed method consists in improving the motor-evacuation function of the proximal duodenum during its transverse intersection, preventing the development of the “lead loop” syndrome and reflux gastritis by switching off the distal part of the duodenum from the passage and using isolated duodenoanastomosis of the duodenum .

Claims (1)

 The method of applying duodenojejunostomy with the annular pancreas by anastomosing the proximal duodenum with the jejunum, characterized in that the duodenum is transversely crossed over the annular pancreas, the distal end of the duodenum of the periosteum is sutured, the anteriosteum is cross-linked and the distal section of the jejunum, and also between the initial and distal sections jejunum.